Retroperitoneal Foregut Duplication Cyst Containing Gastric, Respiratory, and Pancreatic Tissue Misinterpreted as an Adrenal Mass on Imaging: A Case Report and Review of the Literature

Foregut duplication cyst is most commonly seen in the posterior mediastinum without communication with adjacent organs or presence of other malformations and typically shows ectopic gastric or respiratory epithelium. The finding of ectopic pancreatic tissue is extremely rare. A 15-year-old female patient presented with elevated blood pressure, intermittent right flank pain for 18 months. An abdominal MRI revealed a 4 cm right cystic retroperitoneal mass, initially thought to arise from the right adrenal gland. Intraoperatively, the mass was centered in the retroperitoneum between the right adrenal gland and kidney, without attachments to these organs and no communication with other structures, and it was completely excised. Gross examination revealed a 3.5 cm well-circumscribed solid and cystic mass with orange-white cut surface and cloudy fluid surrounded by variable amounts of adipose tissue. On microscopic examination, the cysts were lined by respiratory and gastric antral/oxyntic-type mucosa, surrounded by muscularis mucosae, submucosal tissue, muscularis propria, and perienteric tissue. Within the muscular propria, exocrine pancreatic tissue was also noted. The patient is well with 7-months of follow up. This case is the first one reporting gastric, respiratory, and pancreatic epithelia.

Predictive significance of computed tomography in bilateral sinonasal respiratory epithelial adenomatoid hamartoma

KEY POINTS

Respiratory epithelial adenomatoid hamartoma (REAH) is easily confused with nasal polyps (NP). The typical manifestation of REAH on CT is the enlargement of bilateral olfactory clefts (OCs). The widening of the OCs in the CT scan is a biomarker for diagnosing REAH associated with NP.

Immunological Features of Paranasal Sinus Mucosa in Patients with Graves' Orbitopathy

BACKGROUND

Previous studies showed that patients with Graves' orbitopathy (GO) had concomitant mucosal abnormality within the paranasal sinuses. It remains unknown whether the immunological reactions in sinus mucosa affect the orbit inflammation in GO.

METHODS

Patients with GO underwent sinus computed tomography (CT) scans for sinus mucosal disease by two independent reviewers using the Lund-MacKay systems. Ethmoid mucosal samples were collected during orbital decompression surgeries for patients with GO and correction surgeries for patients with old orbital fractures as controls. Histological analysis and immunofluorescence were performed in all sinus mucosa tissues. Flow cytometry analysis was used to examine the immunological features of sinus mucosa in both GO and control groups.

RESULTS

Immunohistochemistry showed that the paranasal sinus mucosa of patients with GO grew swelling, with goblet cell and small vessel proliferation, endothelial cell swelling, and inflammatory cell infiltration. The number of T helper (Th)1, Th17, and gamma-delta T cells in nasal sinus mucosa of patients with GO increased significantly compared with those from controls. Further, the proportion of Th1 cells was significantly correlated with clinical activity score. In addition, there was a decreased number of regulatory T cells in patients with GO. The number of Th2 cells showed no significant difference between the two groups. Finally, the proportion of interleukin-22-producing cell subsets in gamma-delta T cells of patients with GO was significantly increased compared with those from controls.

CONCLUSIONS

Our observations illustrated a potential pathogenic role of mucosal-infiltrating T cells, which may have the possibility to aggravate inflammatory responses in GO.

Novel automated vessel pattern characterization of larynx contact endoscopic video images

Purpose

Contact endoscopy (CE) is a minimally invasive procedure providing real-time information about the cellular and vascular structure of the superficial layer of laryngeal mucosa. This method can be combined with optical enhancement methods such as narrow band imaging (NBI). However, these techniques have some problems like subjective interpretation of vascular patterns and difficulty in differentiation between benign and malignant lesions. We propose a novel automated approach for vessel pattern characterization of larynx CE + NBI images in order to solve these problems.

Methods

In this approach, five indicators were computed to characterize the level of vessel’s disorder based on evaluation of consistency of gradient and two-dimensional curvature analysis and then 24 features were extracted from these indicators. The method evaluated the ability of the extracted features to classify CE + NBI images based on the vascular pattern and based on the laryngeal lesions. Four datasets were generated from 32 patients involving 1485 images. The classification scenarios were implemented using four supervised classifiers.

Results

For classification of CE + NBI images based on the vascular pattern, polykernel support vector machine (SVM), SVM with radial basis function (RBF), k-nearest neighbor (kNN), and random forest (RF) show an accuracy of 97%, 96%, 96%, and 96%, respectively. For the classification based on the histopathology, Polykernel SVM showed an accuracy of 84%, 86% and 84%, RBF SVM showed an accuracy of 81%, 87% and 83%, kNN showed an accuracy of 89%, 87%, 91%, RF showed an accuracy of 90%, 88% and 91% for classification between benign histopathologies, between malignant histopathologies and between benign and malignant lesions, respectively.

Conclusion

These promising results show that the proposed method could solve the problem of subjectivity in interpretation of vascular patterns and also support the clinicians in the early detection of benign, pre-malignant and malignant lesions.

Molecular subtyping reveals immune alterations associated with progression of bronchial premalignant lesions

Bronchial premalignant lesions (PMLs) are precursors of lung squamous cell carcinoma, but have variable outcome, and we lack tools to identify and treat PMLs at risk for progression to cancer. Here we report the identification of four molecular subtypes of PMLs with distinct differences in epithelial and immune processes based on RNA-Seq profiling of endobronchial biopsies from high-risk smokers. The Proliferative subtype is enriched with bronchial dysplasia and exhibits up-regulation of metabolic and cell cycle pathways. A Proliferative subtype-associated gene signature identifies subjects with Proliferative PMLs from normal-appearing uninvolved large airway brushings with high specificity. In progressive/persistent Proliferative lesions expression of interferon signaling and antigen processing/presentation pathways decrease and immunofluorescence indicates a depletion of innate and adaptive immune cells compared with regressive lesions. Molecular biomarkers measured in PMLs or the uninvolved airway can enhance histopathological grading and suggest immunoprevention strategies for intercepting the progression of PMLs to lung cancer.

Redox imaging and optical coherence tomography of the respiratory ciliated epithelium

Optical coherence tomography (OCT) is an emerging technology for in vivo airway and lung imaging. However, OCT lacks sensitivity to the metabolic changes caused by inflammation, which drives chronic respiratory diseases such as asthma and chronic obstructive pulmonary disorder. Redox imaging (RI) is a label-free technique that uses the autofluorescence of the metabolic coenzymes NAD(P)H and flavin adenine dinucleotide (FAD) to probe cellular metabolism and could provide complimentary information to OCT for airway and lung imaging. We demonstrate OCT and RI of respiratory ciliated epithelial function in ex vivo mouse tracheae. We applied RI to measure cellular metabolism via the redox ratio [intensity of NAD(P)H divided by FAD] and particle tracking velocimetry OCT to quantify cilia-driven fluid flow. To model mitochondrial dysfunction, a key aspect of the inflammatory process, cyanide was used to inhibit oxidative metabolism and reduce ciliary motility. Cyanide exposure over 20 min significantly increased the redox ratio and reversed cilia-driven fluid flow. We propose that RI provides complementary information to OCT to assess inflammation in the airway and lungs.

Respiratory epithelial adenomatoid hamartoma of the olfactory groove: A report of 4 cases and a review of the literature

Respiratory epithelial adenomatoid hamartoma (REAH) is a rare benign lesion that affects the nasal cavity and paranasal sinuses. We present 4 cases of REAH that involved the olfactory clefts; 1 case was bilateral. Each of the cases was treated surgically, and no recurrence was observed. Most reports have indicated that REAH occurs in the presence of sinonasal inflammation, particularly nasal polyposis, yet all 4 of our cases occurred in the absence of concurrent rhinosinusitis. This suggests that the etiology of REAH is multifactorial. In addition, we review the literature on REAH, and we discuss its presentation, differential diagnosis, radiology, histopathology, and underlying treatment principles.

Paranasal sinus opacification at MRI in lower airway disease (the HUNT study-MRI)

The study builds on the concept of united airways, which describes the link between the upper and lower airways. Explorations of this concept have mainly related to asthma and less to chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate paranasal sinus opacification at magnetic resonance imaging (MRI) in COPD, self-reported asthma and respiratory symptoms. In this cross-sectional study, 880 randomly selected participants in the Nord-Trøndelag health survey (HUNT) (mean age 57.7 years, range 50-66 years, 463 women) were investigated using MRI of the paranasal sinuses. Participants were allocated to four mutually exclusive groups: (1) COPD (n = 20), (2) asthma (n = 89), (3) respiratory symptoms (n = 199), and (4) reference group (n = 572). Paranasal sinus opacifications were categorised as mucosal thickening, polyps and retention cysts, and fluid. In each participant, measurements ≥1 mm from all sinuses were summed to give a total for each category of opacities. The sums for these three categories were further added together, and referred to as the total sum. Using the 75th percentile cut-off values, the likelihood of having paranasal sinus opacifications was more than six times higher in participants with COPD and twice as high in participants with asthma than among the reference group. Respiratory symptoms were only associated with mucosal thickening. The present study shows that paranasal sinus opacification is associated not only with asthma, but also with COPD and respiratory symptoms. This is in accordance with the united airways hypothesis, and should be kept in mind when handling patients with these conditions.

Tracking extended mucociliary transport activity of individual deposited particles: longitudinal synchrotron X-ray imaging in live mice

To assess potential therapies for respiratory diseases in which mucociliary transit (MCT) is impaired, such as cystic fibrosis and primary ciliary dyskinesia, a novel and non-invasive MCT quantification method has been developed in which the transit rate and behaviour of individual micrometre-sized deposited particles are measured in live mice using synchrotron phase-contrast X-ray imaging. Particle clearance by MCT is known to be a two-phase process that occurs over a period of minutes to days. Previous studies have assessed MCT in the fast-clearance phase, ∼20 min after marker particle dosing. The aim of this study was to non-invasively image changes in particle presence and MCT during the slow-clearance phase, and simultaneously determine whether repeat synchrotron X-ray imaging of mice was feasible over periods of 3, 9 and 25 h. All mice tolerated the repeat imaging procedure with no adverse effects. Quantitative image analysis revealed that the particle MCT rate and the number of particles present in the airway both decreased with time. This study successfully demonstrated for the first time that longitudinal synchrotron X-ray imaging studies are possible in live small animals, provided appropriate animal handling techniques are used and care is taken to reduce the delivered radiation dose.

Pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma with multiple thin-walled pulmonary cysts: a case report and review of the literature

We herein report a rare case of pulmonary mucosa-associated lymphoid tissue (p-MALT) lymphoma with multiple cystic lesions. A previously healthy 58-year-old Japanese woman visited our hospital for an evaluation of abnormal chest computed tomography (CT) findings. Chest CT revealed multiple cystic lesions in both lungs, and she was diagnosed as having p-MALT lymphoma based on the pathological findings. The patient had no underlying autoimmune diseases. She has not received any chemotherapy and has been stable for two years. This case suggests that, although rare, the possibility of p-MALT lymphoma should be considered in patients with multiple cystic lung diseases.

[Tracheobronchial and pulmonary parenchymatous congenital abnormalities requiring surgical treatment in adults]

Most tracheobronchial and parenchymatous congenital abnormalities of the respiratory system are diagnosed in early life. However, some lesions may be initially silent and diagnosed only in adulthood. These cases included congenital abnormalies of the tracheobronchial tract (tracheal and/or bronchial stenosis, bronchogenic cysts, bronchial atresia, oesotracheal fistula, oesobronchial fistula, and tracheal diverticulum), and lung parenchyma itself (pulmonary sequestration, congenital cystic adenomatoïd malformation, lobar emphysema, lobar or lung hypoplasia). To avoid dreadful complications, these rare cases deserve surgical management, and must be known by chest physicians and surgeons.

A detailed examination of pulmonary uptake of (99m)Tc-Tin colloid in healthy mature miniature pigs

(99m)Tc-Tin colloid is a commonly used colloidal radiopharmaceutical in human medicine for evaluating liver function and morphology. (99m)Tc-Tin colloid is taken up in the liver by the phagocytic activity of Kupffer cells, the reticuloendothelial cells of the liver. Unlike what occurs in human beings, we demonstrated (99m)Tc-Tin colloid uptake within the lungs and liver in healthy, mature, miniature pigs. Our observations may be explained by the presence of pulmonary intravascular macrophages (PIMs) closely apposed to the endothelium of the pulmonary capillaries in several animal species, such as the sheep, horse, goat, cat and pig. In the current study, we compared scintigraphic images using (99m)Tc-Tin colloid in rats with those in mature, miniature pigs, and identified the presence of PIMs, reticuloentothelial cells similar to Kupffer cells, by immunohistochemistry in pigs. Pulmonary uptake of (99m)Tc-Tin colloid occurred only in pigs, and PIMs in the pulmonary capillaries stained positively for mouse monoclonal MAC387 antibodies to macrophages in lung sections, as well as Kupffer cells in liver sections. Therefore, we conclude that the uptake of intravenously injected (99m)Tc-Tin colloid within both Kupffer cells and PIMs results in scintigraphic imaging of the lung and liver in miniature pigs.

Suppressed signal transduction in the bronchial epithelium of patients with systemic sclerosis

INTRODUCTION

Systemic sclerosis (SSc) is an autoimmune disorder, which frequently affects the lungs, with manifestations of interstitial lung disease (ILD) with lung fibrosis and of pulmonary hypertension. The pathogenesis remains largely unrecognised.

OBJECTIVE

The aim of this study was to elucidate the inflammation in the bronchial mucosa in patients with SSc.

SUBJECTS AND METHODS

Twenty-three subjects diagnosed with SSc participated. Twelve of the SSc patients showed signs of ILD, four were smokers and seven were treated with oral corticosteroids. Seventeen non-smoking, age- and sex-matched healthy subjects served as controls. Bronchoscopy was performed to sample endobronchial mucosal biopsies, which were immunohistochemically stained using a panel of antibodies against inflammatory markers.

RESULTS

The number of neutrophils was significantly elevated in the submucosa of SSc patients, regardless of ILD, or whether the subject was smoking or using oral corticosteroids. No up-regulation of neutrophil chemoattractants or cytokines was seen in the bronchial epithelium. The signal transduction pathways and adhesion molecule expression tended to be suppressed or unchanged in SSc patients compared with controls.

CONCLUSION

It is concluded that SSc is associated with a chronic neutrophilic inflammation in the bronchial mucosal, with signs of suppressed signal transduction, regardless of the presence of interstitial lung disease.

Sinus floor elevation using an osteotome technique without grafting materials or membranes

This retrospective study aimed to radiographically assess sinus floor remodeling after using a modified osteotome technique without graft materials or membranes. After pilot drilling, residual bone was fractured and raised with the schneiderian membrane to the final implant length using osteotomes. Self-tapping implants were placed, and restorations were placed 6 months later. Twenty-four patients were available for follow-up after a mean observation period of 17.6 +/- 8.4 months. The implant survival rate at that time was 100%. Bone filling around the implants was measured and compared with baseline digital radiographs. New bone formation was 86.3% +/- 22.1% mesially and 89.7% +/- 13.3% distally. In nine cases, digital volume tomography was used to verify regeneration. Within the limitations of this study, use of the schneiderian membrane led to considerable bone regeneration, and good clinical success was achieved despite the omission of graft materials.

Characterization and biological effect of Buenos Aires urban air particles on mice lungs

Exposure to increased levels of ambient air particulate matter (PM) is associated with increased cardiopulmonary morbidity and mortality. Its association with adverse health effects and the still unclear mechanisms of action are of concern worldwide. Our objective was to analyze air PM from downtown Buenos Aires (UAP-BA), and evaluate its biological impact on normal airways. We studied the inflammatory response to intranasal instillation of UAP-BA in a short-term-exposure mouse model. We analyzed UAP-BA morphology by scanning electron microscopy and characterized particle chemical composition by energy dispersive X-ray analysis and capillary gas chromatography. We evaluated lung changes by histomorphometry and histochemical methods. Regarding size, surface area and distribution, UAP-BA proved to be small spherical ultrafine particles: free, in clusters and associated to a matrix. The particles contained polycyclic aromatic hydrocarbons, polychlorinated biphenyls and almost no metal traces. Histologically, UAP-BA induced the recruitment of phagocytes, a reduction in air spaces, an increase in mucous PAS positive cells and weak incomplete elastic fiber network. Our results demonstrate that UAP-BA causes adverse biological effects on the respiratory tract generating inflammation that, in turn, may cause tissue injury or organ dysfunction and may contribute to the pathogenesis of lung diseases.

Malignant melanoma of the sinonasal mucosa: two case reports and a review

Malignant melanoma of the sinonasal cavity is an uncommon disease, and therefore a limited amount of data exists regarding its optimal treatment. The course of the disease is highly variable. Individual survival is also highly variable, but the overall prognosis is poor; probably because patients generally present at a late stage and because the disease has a proclivity for distant dissemination. We describe 2 recent cases of primary malignant melanoma of the sinonasal mucosa, and we review the literature.

The effect of inhaled budesonide and formoterol on bronchial remodeling and HRCT features in young asthmatics

Asthma is a chronic disease that may cause remodeling of the airways. We aimed to observe the effects of the combined use of inhaled budesonide and formoterol on both the reversibility of remodeling and structural changes in the airways. Thirty-six male patients (age range, 20-31) with mild-to-moderate persistent asthma were given inhaled formoterol and budesonide treatment for three months. Bronchial diameter (BD) and bronchial wall thickness (BWT), as measured by high-resolution computerized tomography, and reticular basement membrane thickness (RBMT), assessed in bronchoscopic biopsy specimens, were compared with pretreatment findings. Twenty-two age-matched male controls were also enrolled. BDs of the patients were significantly smaller than in the controls, whereas BWT and RBMT were greater. After three months BWT and RBMT of the subsegmental airways significantly decreased and BD increased. There was a prominent eosinophilic and lymphocytic infiltration in the bronchial mucosa of the asthmatics, and the eosinophilic infiltration significantly improved with treatment. Both serum total IgE and eosinophil counts were related to eosinophilic infiltration in the biopsy samples (r = 0.494 and r = 0.463, respectively). FEV(1) was positively correlated with the diameters of the segmental and subsegmental airways (r = 0.491 and r = 0.265, respectively) and negatively correlated with BWT of the subsegmental airways (r = -0.293) and with the RBMT of both the segmental and subsegmental airways (r = -0.597 and r = -0.590, respectively). We suggest that treatment with inhaled formoterol and budesonide may reverse increased RBMT and BWT as part of remodeling in patients with asthma.

Evaluation of two-way protein fluxes across the alveolo-capillary membrane by scintigraphy in rats: effect of lung inflation

Pulmonary microvascular and alveolar epithelial permeability were evaluated in vivo by scintigraphic imaging during lung distension. A zone of alveolar flooding was made by instilling a solution containing99mTc-albumin in a bronchus. Alveolar epithelial permeability was estimated from the rate at which this tracer left the lungs. Microvascular permeability was simultaneously estimated measuring the accumulation of111In-transferrin in lungs. Four levels of lung distension (corresponding to 15, 20, 25, and 30 cmH2O end-inspiratory airway pressure) were studied during mechanical ventilation. Computed tomography scans showed that the zone of alveolar flooding underwent the same distension as the contralateral lung during inflation with gas. Increasing lung tissue stretch by ventilation at high airway pressure immediately increased microvascular, but also alveolar epithelial, permeability to proteins. The same end-inspiratory pressure threshold (between 20 and 25 cmH2O) was observed for epithelial and endothelial permeability changes, which corresponded to a tidal volume between 13.7 ± 4.69 and 22.2 ± 2.12 ml/kg body wt. Whereas protein flux from plasma to alveolar space (111In-transferrin lung-to-heart ratio slope) was constant over 120 min, the rate at which99mTc-albumin left air spaces decreased with time. This pattern can be explained by changes in alveolar permeability with time or by a compartment model including an intermediate interstitial space.

Radiology of Severe Acute Respiratory Syndrome (SARS)

Severe acute respiratory distress syndrome (SARS) caused by SARS-associated coronavirus (SARS-CoV) is a systemic infection that clinically manifests as progressive pneumonia. During the initial phases of infection the virus causes pauci-inflammatory alveolar and interstitial edema that result in imaging abnormalities dominated by ground glass opacities (GGO). Severe SARS cases can develop radiologic and pathologic findings of diffuse alveolar damage. Although radiologic evidence of acute bronchiolitis is absent, SARS-CoV also infects ciliated airway epithelium, probably accounting for respiratory transmissibility of the virus. Radiologic recovery from SARS can be complete, but computed tomography images often show persistent GGO and reticular opacities, some of which reflect pathologic findings of fibrosis. Long-term follow-up imaging of survivors shows gradual decrease of GGO and reticulation with persistent air trapping in some patients. The latter is evidence of small airway disease that is not radiologically evident at the onset of the disease.

Computed tomography evaluation of paranasal sinuses in asthma: is there a tendency of particular site involvement?

Although the precise mechanism is unclear, asthma and chronic sinusitis are associated frequently. Computed tomography (CT) is a sensitive modality for documenting sinonasal mucosal abnormalities. The aim of this study was to evaluate paranasal mucosal abnormalities in asthma and whether there was a relationship with asthma severity. One hundred fifty-five patients with asthma and 36 normal control subjects were assessed with coronal sinus CT. Asthma was classified as mild, moderate, or severe. Scoring of paranasal sinus abnormalities were assessed for total sinus, total mucosal, and individual sites. The mean scores of total mucosal changes (8.45 points versus 4.67 points, p < 0.001) and total sinus scores (5.50 versus 2.69, p < 0.005) were significantly higher in the asthmatic patients compared with controls. Nasal passage and frontal sinus involvements were not statistically different between groups, but all other individual scores were significantly higher in asthmatic patients. There was an involvement site tendency with respect to increasing severity of asthma. Mean total mucosal CT scores (12.57 points versus 7.33 points, p < 0.05) and individual site scores were statistically higher in asthmatic patients with high blood eosinophil levels compared with those patients with normal blood eosinophil counts except for nasal passage disease. There was no significant relationship between total IgE level and CT scores. Total mucosal and sinus scores were significantly related with asthma severity. There was an involvement tendency of sinuses and sites. Nasal passage involvement was unrelated with asthma. Ethmoidal sinuses and ostiomeatal complexes were involved significantly in patients with mild asthma, whereas maxillary, frontal, and sphenoidal sinuses were involved significantly in patients with severe asthma.

Usefulness of preoperative endobronchial ultrasound for airway invasion around the trachea: esophageal cancer and thyroid cancer

BACKGROUND

It is important to confirm preoperative tracheobronchial invasion to enable the selection of the most appropriate treatment.

OBJECTIVE

This study was performed to compare the usefulness of computed tomography (CT), magnetic resonance image (MRI) and bronchoscopy by endobronchial ultrasonography (EBUS) for the assessment of invasion of thyroid or esophageal cancer in cases with suspected tracheobronchial invasion.

METHODS

In cases with suspected contact between the tumor and tracheobronchial wall, CT, MRI and EBUS indicated deformity of the tracheobronchial wall due to the adjacent mass. The final diagnosis was based on surgical and histological results, and/or clinical follow-up.

RESULTS

Fifty-four patients were included in this study. Based on the findings of CT, MRI and EBUS, invasion was suspected in 29, 28 and 25 patients, respectively. Seventeen patients did not undergo surgery based on the results of CT, MRI and bronchoscopy with EBUS. Final diagnosis was intact trachea or bronchial adventitia in 26 patients and invasion in 28 patients. The sensitivity and specificity of CT, MRI and EBUS for invasion were 59 and 56, 75 and 73, and 92 and 83%, respectively. The accuracy of EBUS was significantly greater than that of CT in the present study (p = 0.0011). The accuracy of EBUS was significantly different from that of CT and MRI in the surgically treated patients (p = 0.005 and p = 0.032, respectively).

CONCLUSION

EBUS is the most useful technique for determining the depth and extent of tumor invasion into the airway wall. The combination of MRI and EBUS will contribute to surgical planning in patients with esophageal and thyroid cancer.

Distribution of intranasal C-zolmitriptan assessed by positron emission tomography

Nine healthy volunteers aged 18-28 years were recruited into this open, single-centre, two-phase trial. In phase 1, two volunteers received a single dose of 11C-zolmitriptan 2.5 mg administered as a nasal spray and then underwent positron emission tomography (PET) scanning to determine the most appropriate times for scanning in phase 2. In phase 2, six volunteers received two doses and an additional volunteer one dose of 11C-zolmitriptan 2.5 mg intranasally. Volunteers underwent PET scanning over sectors covering one of the nasopharynx, lungs or abdomen, for up to 1.5 h postdose. The brain was also scanned and plasma zolmitriptan levels were measured. Almost 100% of the administered dose was detected in the nasopharynx immediately after dosing. This declined thereafter to about 50% at 20 min and to 35% at 80 min after dosing. Radioactivity appeared slowly in the upper abdomen, with 25% of given radioactivity detected at 20 min and persisting until 80 min after dosing. Minimal radioactivity was detected in the lungs. Radioactivity was detectable within brain tissue suggesting central penetration of zolmitriptan. Zolmitriptan in plasma had approached its maximum concentration by 15 min postdose. The data indicate initial absorption across the nasal mucosa contributing to an early systemic availability. 11C-Zolmitriptan administered intranasally was well tolerated.

Roots of the maxillary first and second molars in horizontal relation to alveolar cortical plates and maxillary sinus: computed tomography assessment for infection spread

The purposes of this study were to investigate the horizontal relationship of the roots of maxillary molars with the cortical plates and the maxillary sinus and to investigate the influence of these relationships on the spread of odontogenic infection. Computed tomography images of 120 control subjects and 49 patients with infection originating in the maxillary first or second molar were investigated. In the control group, more than 60% of the first molar roots contacted both palatal and buccal cortical plates (type A), while such contact was not seen in more than 60% of second molars. The floor of maxillary sinus was most frequently observed at the level between the bifurcation and apices of roots in both first and second molars. In patients with infection, cortical changes were more frequently seen on the buccal side than on the palatal side, and 80% of patients with buccal cortical change showed the position in which the buccal roots were close to the buccal cortical plate. Mucosal thickening of the maxillary sinus was found in 87.8%. The buccopalatal spread of odontogenic infection originating in the maxillary first and second molars was influenced by the horizontal root position in relation to the cortices.

Detection of alveolar epithelial injury by Tc-99m DTPA radioaerosol inhalation lung scan in rheumatoid arthritis patients

Rheumatoid arthritis (RA) is a systemic autoimmune disorder primarily involving the joints. Lung alterations in RA may be primary or secondary to pharmacological treatments and may involve the alveoli, interstitium, airways and/or pleura. Technetium-99m diethylenetriaminepentaacetic acid (Tc-99m DTPA) aerosol inhalation scintigraphy is a sensitive and noninvasive test commonly employed to assess pulmonary epithelial membrane permeability. The purpose of the this study was a) to investigate the changes of pulmonary alveolar epithelial permeability in patients with RA, b) to determine the relationship between the clearance rate of Tc-99m DTPA and pulmonary function test (PFT) results, and c) to determine the relationship between the clearance rete of Tc-99m DTPA and clinical parameters of disease. Twenty-five patients with RA but without lung alterations were included in the study. The patients were 22 females, and 3 males; mean age 53.6 +/- 8.7 years. Technetium-99m DTPA aerosol inhalation scintigraphy was performed on the study and healthy control groups. Clearance half times (T1/2) were calculated by placing a mono-exponential fit on the curves. Penetration index (PI) was calculated on the first-minute image. There were no significant differences in the mean T1/2 or mean PI values between the RA patients and control subjects. No correlation was found between the mean T1/2 values of Tc-99m DTPA clearance and activity of RA, clinical values, or the spirometric measurements except FEV1/FVC and functional status in RA patients (p = 0.02, p = 0.01, respectively). However, a weak correlation was found between duration of disease and T1/2 values of Tc-99m DTPA clearance (p = 0.006). PI values tended to correlate with FEF25-75, although, this was not statistically significant (p = 0.057). This study shows that no changes occur in alveolar-capillary permeability in RA patients without lung alterations.

Pulmonary epithelial permeability in patients treated with bleomycin containing chemotherapy detected by technetium-99m diethylene triamine penta-acetic acid aerosol (99mTc-DTPA) scintigraphy

PURPOSE

To evaluate pulmonary epithelial permeability using 99mTc-DTPA scintigraphy in patients treated with bleomycin-containing regimens.

MATERIAL AND METHODS

Twelve non-smoking chemotherapy-naïve patients with no clinical or radiological evidence of pulmonary disease and treated with bleomycin-containing chemotherapy were tested with 99mTc-DTPA scintigraphy before the first cycle and every 3 weeks until the third month after the end of chemotherapy (total cumulative dose of bleomycin 347.9 mg).

RESULTS

Pretreatment values (T1/2 74.93 minutes) of 99mTc-DTPA scintigraphy were significantly higher than those obtained after the total dose of bleomycin (T1/2 51.00 minutes) (p < 0.001). This difference was more important in the later evaluations especially, on the third week and third month measures after discontinuing treatment (p < 0.001). All the tests of Within-Subjects Effects were significant (p < 0.001). Comparing pretreatment and post-treatment scintigraphies the mean T1/2 99mTc-DTPA values decreased as the bleomycin dose increased.

CONCLUSION

We conclude that cumulative bleomycin doses are related to increased pulmonary epithelial permeability at a dose of 256.5 mg. However, whether this is related to clinical toxicity is uncertain and large, multi-center prospective studies are needed.

Anatomic variations of the sphenoid sinus on computed tomography

Anatomic variations of the vital structures adjacent to the sphenoid sinus can be jeopardized during functional endoscopic sinus surgery (FESS). The knowledge of the size and extent of pneumatization of the sphenoid sinus (SS) is an important condition for adequate surgical treatment of its disease. The bony anatomic variations of SS as well as its relationship with adjacent vital structures were reviewed in this paper. The study was performed on 267 patients with a complaint of chronic or recurrent sinusitis. Computed tomographic (CT) scans were obtained upon completion of therapy. The evaluations of the sphenoid sinuses were regarded separately, so as 534 sides were examined. Especially bony anatomic variations as well as mucosal abnormalities of the sphenoid sinuses were examined. Pneumatization of the pterygoid process and anterior clinoid process were found in 39.7% and 17.2% of the patients respectively. Vidian canal protrusion was found in a total of 158 sides of which 60 were bilateral. These entities were encountered usually when pneumatization of the pterygoid process occurred. Carotid canal and optic canal protrusions were found in 5.2% and 4.1% of the patients respectively. Mucosal thickening, and polyps or cysts of sphenoid sinuses were detected in 20.6% and 4.5% of the patients respectively. There was a statistically significant correlation between pterygoid pneumatization and vidian canal protrusion (p < 0.001), and vs. foramen rotundum protusion (p = 0.004). While the optic canal protrusion was found significantly associated with the anterior clinoid pneumatization (p < 0.001), there was no statistically significant correlation between a carotid canal protrusion and anterior clinoid pneumatization (p = 0.250). Sphenoid sinus surgery is very risky, because of changing variations of the cavity. We are in the opinion that detailed data from CT scans of SS will enable the surgeon to interpret any anatomic variations and pathological conditions before initiation of the surgical therapy.

Subclinical alveolar involvement in ulcerative colitis

BACKGROUND

Although pulmonary dysfunction has been described in patients with ulcerative colitis (UC), the pathogenesis remains unclear. Our aim was to study alveolar epithelial damage using technetium-99m diethylene triamine penta acetic acid (Tc-99m DTPA) aerosol scintigraphy in patients with UC but without respiratory symptoms.

METHODS

We enrolled 32 patients (18 women and 14 men; mean age, 36.4 +/- 11.6 yr) with active UC, 10 patients with inactive UC (6 women and 4 men; mean age, 43.4 +/- 11.8 yr), and 31 healthy controls (24 women and 7 men; mean age, 40 +/- 10 yr). Tc-99m DTPA aerosol scintigraphy was performed on all patients and controls. The relationship between alveolar epithelial permeability and the activity, localization, and duration of the disease was studied.

RESULTS

There was a significant difference between alveolar epithelial permeability results in patients with active UC and those of the controls (P < 0.001). The same correlation was also found between the patients with inactive UC and the control group (P < 0.001). There was no correlation between Tc-99m DTPA alveolar scintigraphic test results and the stage of activity, localization, and duration of the disease.

CONCLUSIONS

A latent pulmonary involvement may exist in patients with active and inactive UC. The alveolar involvement may be the earliest pulmonary damage, and a DTPA clearance test may show the early changes in pulmonary epithelial permeability that precedes clinical symptoms. Increased alveolar epithelial permeability is an extraintestinal manifestation in patients with UC and is not related to the activity of the colitis.

Detection of alveolar epithelial injury by99mTc-DTPA radioaerosol inhalation lung scan following blunt chest trauma

DTPA clearance rate is a reliable index of alveolar epithelial permeability, and is a highly sensitive marker of pulmonary epithelial damage, even of mild degree. In this study, 99mTc-DTPA aerosol inhalation scintigraphy was used to assesss the pulmonary epithelial membrane permeability and to investigate the possible application of this permeability value as an indicator of early alveolar or interstitial changes in patients with blunt chest trauma. A total of 26 patients was chest trauma (4 female, 22 male, 31-80 yrs, mean age; 53+/-13 yrs) who were referred to the emergency department in our hospital participated in this tsudy. Technetium-99m diethylene triamine pentaacetic acid (DTPA) aerosol inhalation scintigraphy was performed on the first and thirtieth days after trauma. Clearance half times (T1/2) were calculated by placing a mono-exponential fit on the curves. Penetration index (PI) was calculated on the first-minute image. On the first day, mean T1/2 value of the whole lung was 63+/-19 minutes (min), and thirtieth day mean T1/2 value was 67+/-21 min. On the first day, mean PI values of the lung and 30th day mean PI value were 0.60+/-0.05, and 0.63+/-0.05, respectively. Significant changes were observed in radioaerosol clearance and penetration indices. Following chest trauma, clearance of 99mTc-DTPA increased owing to breakdown of the alveolar-capillary barrier. This increase in the epithelial permeability of the lung appears to be an early manifestation of lung disease that may lead to efficient therapy in the early phase.

[CT findings of pulmonary hamartoma with special reference to epithelial-lined clefts and connection with pulmonary arteries]

PURPOSE

The purpose of this study was to clarify the characteristic CT findings of pulmonary hamartoma.

MATERIALS AND METHODS

The thin-section CT and multiplanar reformation images of 19 pulmonary hamartomas diagnosed by surgical resection were analyzed and correlated with the pathological findings.

RESULTS

Most hamartomas presented lobulated nodules apart from pleura. There was no case in which fat density was recognized. Only one case was recognized as having calcification. Air density in the connection of the side or the inside was pointed out in 5 cases (26%). Air density reflected epithelial-lined cleft. The connection with the bronchus was recognized in 4 cases (21%), and the connection with the pulmonary artery branch was recognized in 10 cases (53%). However, the connection of the pulmonary artery and bronchus could not be pathologically confirmed in most cases. The connection with the pulmonary vein was not recognized in any of the cases.

CONCLUSION

Air density in the connection of the side or the inside is characteristic of pulmonary hamartoma. Pulmonary artery branches connect beyond half of hamartomas. This finding suggests close relations in the bronchus along the artery. It is important that there is no connection of the pulmonary vein, to differentiate it from lung cancer.

Effect of short-term treatment with inhaled corticosteroid on airway wall thickening in asthma

PURPOSE

Computed tomography studies demonstrate thickening of the asthmatic airway wall and its relation to disease severity. We evaluated the effect of inhaled corticosteroid on this phenomenon.

METHODS

Cross-sectional images of the right upper lobe apical segmental bronchus were obtained by helical computed tomography in 45 corticosteroid-naïve patients with persistent asthma and 28 healthy controls. Airway wall thickness was measured as airway wall area normalized to body surface area. Computed tomography, pulmonary function, and serum levels of eosinophil cationic protein were examined before and after treatment with beclomethasone (800 microg/d for 12 weeks).

RESULTS

Before treatment, airway wall thickness was greater in asthma patients than in controls (P <0.0001). After treatment, it decreased by 11% (P <0.001) but remained high (P <0.0001 vs. control); the serum level of eosinophil cationic protein decreased, and airflow obstruction was reduced, but not to the level in controls. The decrease in wall thickness was associated with a decrease in the serum level of eosinophil cationic protein (r = 0.39, P = 0.009) and an increase in the forced expiratory volume in 1 second (r = 0.45, P = 0.003) and was inversely related to disease duration at entry (r = -0.38, P = 0.009). Post-treatment wall thickness was related to disease duration (r = 0.45, P = 0.003) and remaining airflow obstruction.

CONCLUSION

Wall thickening of asthmatic central airways responds partially to inhaled corticosteroid therapy and may reflect an overall reduction in airway inflammation. "Unresponsive components," possibly involving structural changes, may increase in the absence of inhaled corticosteroid treatment, potentially leading to chronic airflow obstruction.

The bronchoalveolar epithelial permeability in house painters as determined by Tc-99m DTPA aerosol scintigraphy

PURPOSE

Isocyanates are highly reactive chemicals used in a number of industries including paints. Therefore, house painters are known to be at risk for occupational exposure to isocyanates. Our objectives in this study were: (1) to investigate the possible effects of isocyanate exposition on the bronchoalveolar epithelial permeability in house painters by using Tc-99m DTPA radioaerosol lung scintigraphy; (2) to assess whether or not some differences exist between asthmatic and non-asthmatic house painters, and (3) to determine the relationship between Tc-99m DTPA radioaerosol lung scintigraphy and the spirometric measurements, and the work duration of house painters.

MATERIALS AND METHODS

Ten non-smoking house painters (28.8 +/- 8.8 yrs) and ten healthy volunteers underwent Tc-99m DTPA radioaerosol lung scintigraphy. Following inhalation of radiotracer through a nebulizer for 5 minutes, dynamic scintigrams (1 frame/min, up to 10 min) were taken from both lungs. ROI's were drawn over the both lung area, and time-activity curves were obtained, from which the half-time (T1/2) of Tc-99m DTPA clearance was calculated. Spirometric lung function test was measured in all house painters.

RESULTS

Mean T1/2 values (min +/- SD) were 93.74 +/- 32.79 for house painters, and 90.96 +/- 40.02 for control subjects. There was no significant difference in T1/2 values of Tc-99m DTPA clearance between house painters and controls, and between asthmatic and non-asthmatic house painters as well. No correlation was observed between T1/2 values of Tc-99m DTPA clearance and spirometric measurements. In house painters, there was a positive correlation between T1/2 values of Tc-99m DTPA clearance and work duration (r = 0.73, p = 0.016).

CONCLUSIONS

Our findings indicate that in house painters, occupational exposure to isocyanates has no effect on bronchoalveolar epithelial permeability, and the rate of Tc-99m DTPA clearance shows no difference between asthmatic and non-asthmatic house painters. The positive correlation between the rate of Tc-99m DTPA clearance and work duration needs to be confirmed in larger cohorts.

The influence of volatile anesthetics on alveolar epithelial permeability measured by noninvasive radionuclide lung scan

Many volatile anesthetics have long been thought to affect pulmonary functions including lung ventilation (LV) and alveolar epithelial permeability (AEP). The purpose of this study is to examine the influence of volatile anesthetics on LV and AEP by noninvasive radionuclide lung imaging of technetium-99m labeled diethylene triamine pentaacetic acid radioaerosol inhalation lung scan (DTPA lung scan). Twenty patients undergoing surgery and receiving volatile anesthesia with 1% halothane were enrolled as the study group 1. The other 20 patients undergoing surgery and receiving volatile anesthesia with 1.5% isoflurane were enrolled as the study group 2. At the same time, 20 patients undergoing surgery with intravenous anesthesia drugs were included as a control group. Before surgery, 1 hour after surgery, and 1 week after surgery, we investigated the 3 groups of patients with DTPA lung scan to evaluate LV and AEP by 99mTc DTPA clearance halftime (T1/2). No significant change or abnormality of LV before surgery, 1 hour after surgery, or 1 week after surgery was found among the 3 groups of patients. In the control group, the 99mTc DTPA clearance T1/2 was 63.5 +/- 16.4, 63.1 +/- 18.4, and 62.8 +/- 17.0 minutes, before surgery, 1 hour after surgery, and 1 week after surgery, respectively. In group 1, it was 65.9 +/- 9.3, 62.5 +/- 9.1, and 65.8 +/- 10.3 minutes, respectively. No significant change in AEP before surgery, 1 hour after surgery, or 1 week after surgery was found. However, in group 2, the 99mTc DTPA clearance T1/2 was 65.5 +/- 13.2, 44.9 +/- 10.5, and 66.1 +/- 14.0 minutes, respectively. A significant transient change in AEP was found 1 hour after surgery, but it recovered 1 week after surgery. We conclude that volatile anesthesia is safe for LV and AEP, and only isoflurane can induce transient change of AEP.

[Evaluation of the functional activity of the bronchial mucosa in pulmonary tuberculosis and other lung diseases]

Tracheobronchography using tantal powder was used to study the functional activity of the intact and altered bronchial mucosa that manifested itself as the unchanged outline of the mucosa and its clearance (mucociliary clearance). With the intact mucosa, the sequence of its clearance was established; the mechanism of powder transport was studied, which showed up as the appearance of metachronal fields, fusion of particles into conglomerates that form currents that direct towards the larynx. The clearance of the mucosa was over by hours 20-24. With the altered mucosa (tuberculosis and other diseases), the sequence and mechanism of its clearance were impaired. The outline of the mucosa was chaotic; there was a long powder retention (48-72-hour or more) in cancer and bronchoectases. There was retrograde transport of particles into the minor bronchi. The found differences in the activity of the mucosa in pulmonary tuberculosis and lung cancer allow this method to be used for differential diagnosis.

Impaired lung epithelial permeability in hepatitis C virus antibody positive patients detected by 99mTc-DTPA aerosol scintigraphy

Chronic hepatitis C virus (HCV) infection has been recently identified as an aetiological agent in idiopathic pulmonary fibrosis. The present study was designed to determine the pulmonary clearance rate of 99mTc-diethylenetriaminepentaacetic acid (99mTc-DTPA) in asymptomatic HCV antibody positive (HCV Ab+) patients and the role of 99mTc-DTPA aerosol scintigraphy in the early detection of lung involvement. Twenty-six non-smoker HCV Ab+ and HCV-RNA (+) patients (20 female, six male; aged 43+/-11 years), with no clinical pulmonary symptoms, and normal radiological findings, were studied. Thirty-one healthy non-smoker volunteers (24 female, seven male; aged 40+/-10 years) were taken as a control group. 99mTc-DTPA aerosol inhalation scintigraphy and pulmonary function tests were performed in all patients and in controls. On the basis of the scintigrams the percentage decline in activity per minute (Kep) was evaluated, which represented an accurate parameter of lung membrane permeability. The mean Kep values of healthy controls (0.78+/-0.13 for left lung, 0.79+/-0.14 for right lung) were significantly lower than HCV Ab+ patients (1.10+/-0.31 for left lung, 1.11+/-0.34 for right lung, P<0.001). But no significant change was observed in PFT (P>0.05). We conclude that subclinical alveolitis and/or interstitial lung disease may be present in patients with HCV Ab+, since it is known that an increase in the epithelial permeability of the lung is an early manifestation of interstitial disease.

Methodology for the measurement of mucociliary function in the mouse by scintigraphy

The objective of the study was to develop a scintigraphic method for measurement of airway mucociliary clearance in small laboratory rodents such as the mouse. Previous investigations have characterized the secretory cell types present in the mouse airway, but analysis of the mucus transport system has been limited to in vitro examination of tissue explants or invasive in vivo measures of a single airway, the trachea. Three methods were used to deposit insoluble, radioisotopic colloidal particles: oropharyngeal aspiration, intratracheal instillation, and nose-only aerosol inhalation. The initial distribution of particles within the lower respiratory tract was visualized by gamma-camera, and clearance of particles was followed intermittently over 6 h and at the conclusion, 24 h postdelivery. Subsets of mice underwent lavage for evidence of tissue inflammation, and others were restudied for reproducibility of the methods. The aspiration and instillation methods of delivery led to greater distributions of deposited activity within the lungs, i.e., approximately 60--80% of the total respiratory tract radioactivity, whereas the nose-only aerosol technique attained a distribution of 32% to the lungs. However, the aerosol technique maximized the fraction of particles that cleared the airway over a 24-h period, i.e, deposited onto airway epithelial surfaces and cleared by mucociliary function such that lung retention at 24 h averaged 57% for delivery by aerosol inhalation and > or =80% for the aspiration or intratracheal instillation techniques. Particle delivery methods did not cause lung inflammation/injury with use of inflammatory cells and chemoattractant cytokines as criteria. Scintigraphy can discern particle deposition and clearance from the lower respiratory tract in the mouse, is noninvasive and reproducible, and includes the capability for restudy and lung lavage when time course or chronic treatments are being considered.

Use of ciliogenesis in the diagnosis of primary ciliary dyskinesia in a dog

Primary ciliary dyskinesia is a congenital condition that may cause chronic rhinitis and bronchopneumonia. Primary ciliary dyskinesia may be diagnosed by induction of ciliogenesis by use of in vitro cell culture. Induction of ciliogenesis allows for differentiation between primary and secondary ciliary dyskinesia.

Mucosal detail at CT virtual reality: surface versus volume rendering

PURPOSE

To evaluate computed tomographic virtual reality with volumetric versus surface rendering.

MATERIALS AND METHODS

Virtual reality images were reconstructed for 27 normal or pathologic colonic, gastric, or bronchial structures in four ways: the transition zone (a) reconstructed separately from the wall by using volume rendering; (b) with attenuation equal to air; (c) with attenuation equal to wall (soft tissue); (d) with attenuation halfway between air and wall. The four reconstructed images were randomized. Four experienced imagers blinded to the reconstruction graded them from best to worst with predetermined criteria.

RESULTS

All readers rated images with the transition zone as a separate structure as overwhelmingly superior (P <.001): Nineteen cases had complete concurrence among all readers. The best of the surface-rendering reconstructions had the transition zone attenuation equal to the wall attenuation (P <.001). The third best reconstruction had the transition zone attenuation equal to the air attenuation, and the worst had the transition zone attenuation halfway between the air and wall attenuation.

CONCLUSION

Virtual reality is best with volume rendering, with the transition zone (mucosa) between the wall and air reconstructed as a separate structure.